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¹ “Structural racism” is the totality of ways in which a society fosters racial and ethnic inequity and subjugation through mutually reinforcing systems, including housing, education, employment, earnings, benefits, credit, media, health care, and the criminal legal system. These structural factors organize the distribution of power and resources (i.e., the social determinants of health) differentially among racial, ethnic, and socioeconomic groups, perpetuating racial and ethnic health inequities. The key difference between institutional and structural racism is that structural racism happens across institutions, while institutional racism happens within institutions. “Systemic racism” is another term used to describe this (NASEM, 2023a, p. xxv).

recognizing that racist ideas have shaped public health practice and stressed that health equity could not be achieved without addressing systemic racism (Bassett and Graves, 2018).

Some have posited that cannabis legalization could reduce social inequities by mitigating the adverse consequences of the criminalization of cannabis use, possession, and sales, which has targeted minoritized groups (Golub et al., 2007; Resing, 2019). However, legalization does not eliminate cannabis policing, and increased policing in minoritized neighborhoods can happen for reasons unrelated to cannabis (Hinton and Cook, 2021). Moreover, even in states with legal cannabis markets, there are laws to be enforced, such as the prohibition of sales to those less than 21 years of age, laws banning smoking in public or near certain buildings, and bans on cannabis-impaired driving, all of which could be unequally enforced (Kilmer, 2019).

There are many reasons to be concerned about how the legal cannabis industry contributes to health inequities. Disproportionate marketing toward minoritized groups and concentration of retail stores in the neighborhoods in which they live, for example, could lead to unequal distribution of the health impacts of cannabis use. This chapter evaluates the impacts of cannabis policy on health equity by considering the criminal justice consequences of cannabis prohibition, assessing social equity programs adopted in some states, and evaluating the effects of cannabis policies on social determinants of health.

IMPACTS ON HEALTH EQUITY RELATED TO CRIMINAL JUSTICE

Entanglements with the criminal justice system can contribute to health inequities when increased policing or racism contributes to disparities in arrests and incarceration. Following incarceration, individuals are at increased risk of morbidity and mortality compared with the general U.S. population (Wang and Shavit, 2023; Wildeman and Wang, 2017). The stigma of a criminal record impacts not only those who committed the offense, but also the health of family members (Wildeman and Wang, 2017). Incarceration is associated with higher rates of chronic health conditions among both adults and children in the family (Wildeman and Wang, 2017; Wildman et al., 2019). There are stark differences by race in this regard; nearly 25 percent of Black Americans have three or more immediate family members who have been incarcerated for any reason, compared with just over 5 percent of White Americans (Sundaresh et al., 2021).

Impacts of Cannabis Arrests

Cannabis arrests have varying impacts on people’s lives. From 2010 to 2019, there was an average of 692,115 cannabis arrests a year (Chapter 1), very few of which resulted in incarceration (Kachnowski et al., 2023).

In some cases, arrest may cause people to make changes that positively impact their lives. However, others are negatively affected, and some are incarcerated, which impacts their health and well-being. To learn more about those experiences, the committee invited speakers affiliated with the Last Prisoner Project² (Jason Ortiz, Donte West, Stephanie Shepherd, and Kyle Page) to describe how the criminal justice system has impacted their lives. All four speakers shared stories of the devastating impact of cannabis-related criminal justice entanglements; none had faced charges of violent crime.

Jason Ortiz described his arrest for cannabis use as a teen, the fear when he was arrested at school, how he almost did not graduate high school, and how he benefited from a change in Connecticut’s Higher Education Act that removed the federal aid elimination penalty from his arrest.

Donte West described the emotional toll and the fight to overturn his conviction for possessing a pound of cannabis. West emphasized that his conviction impacted his life in ways that cannot be quantified and said, “When you get incarcerated, not only your freedom gets taken away, but also you don’t get to make memories with your loved ones.”

Kyle Page highlighted the dehumanization during sentencing and the struggle to rebuild a life after prison, especially with regard to employment and family relationships. Kyle shared his experience of being sentenced for cannabis possession. His lawyer explained they needed to “humanize” him for the judge. Page said:

Stephanie Shepherd emphasized the long-term consequences of arrest and incarceration, including limitations on housing, credit, and professional opportunities. She was age 30 when she began using cannabis, 41 when she was convicted of conspiracy to distribute cannabis, and 50 when she was released. Now, at age 54, she still struggles to get her life back together. Shepherd described the shameful feeling she had when she first tried to find employment after release. She said,

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² Video recordings of the committee’s public meetings can be found on the project page: https://www.nationalacademies.org/our-work/public-health-consequences-of-changes-in-the-cannabis-landscape.

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³ The national data reported before 2021 were found in the Federal Bureau of Investigation’s (FBI’s) annual Crime in the United States report. These data underestimate the total number of cannabis possession arrests because of a recording procedure known as the “hierarchy rule,” which means that if someone is arrested for multiple offenses at the same time, only the most serious one is reported to the FBI (e.g., if someone were arrested for robbery and cannabis possession, the law enforcement agency would record only the robbery arrest since it was more serious). In 2021, the FBI began requiring all states to comply with the National Incident-Based Reporting System, which allows multiple offenses to be linked to a particular arrest. However, not all localities are yet compliant, and compliance varies by jurisdiction (NASEM, 2023b).

⁴ The FBI reported that in 2002, there were 1,538,813 arrests for drug abuse violations, and 39.9 percent of these were for cannabis possession, meaning there were 613,986 cannabis possession arrests (Tables 28 and 29, FBI UCR, 2003). The comparable figure for 2019 was 500,395 cannabis possession arrests (1,558,862 * 32.1%). The 2019 data are the most up-to-date and reliable information because data for other years may have been impacted by missingness due to the COVID-19 pandemic (FBI CJISD, 2019).

⁵ In analyses presented in Chapter 3, the committee found that there were approximately 2.1 billion days of cannabis use in 2002. By 2019, that figure had increased to 5.5 billion days. Using the arrest data from the FBI, this means that arrests per million use days decreased from roughly 292 in 2002 to 91 in 2019, or 69%.

⁶ Some analyses in Gunadi and Shi (2022b) include Florida, and thus reflect data from 37 states.

colleagues use 43 states) and focus on arrests of both Black and White people.⁷ The levels and trends are similar across both datasets; the correlation coefficient for cannabis possession arrests of Black people for the two datasets was 0.998, while that for cannabis possession arrests of White people was 0.997 (Figure 5-1). Comparing total cannabis possession arrests for 2002–2004 and 2017–2019 (3-year periods used to mitigate single-year anomalies), data from both papers show large reductions in arrests for White people over both periods (Gunadi and Shi: –22.7 percent; Sheehan

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⁷ As noted by Gunadi and Shi (2022b): “Finally, the UCR data has limited information on arrests by race. Other than arrest data for Blacks and Whites, data are only available for American Indians and Asians. Ethnicity information, such as Hispanic origins, is unavailable for most of the years” (p. 2).

et al.: –24.6 percent). For Black people, however, the data show nearly the opposite, with both data sources documenting substantial increases (Gunadi and Shi: 28.1 percent; Sheehan et al.: 26 percent). While these data have limitations and do not cover the entire country, they emphasize continued inequity in arrests for cannabis possession and deserve additional analysis (Gunadi and Shi, 2022a; Sheehan et al., 2021).

Collateral Consequences

The health and economic impacts of arrests and incarceration extend far beyond the initial punishment. Laws, regulations, and the policies of private organizations, including businesses and educational institutions, as well as social stigma, all contribute to the harms people experience after entanglement in the criminal justice system. Examples include job loss, housing insecurity, and limitations on educational and business opportunities. Collateral consequences for families and communities are discussed below (Maurer, 2017).

Impacts of Incarceration on Economic Security

Incarceration of youth is associated with limited educational opportunities, with subsequent adverse impacts on economic security and wage growth (Western, 2002). Criminal arrests during adolescence are associated with greater criminal activity in young adulthood and midlife, further limiting educational and employment opportunities (Green et al., 2019). Formerly incarcerated people are twice as likely as the general public to fail to complete high school or obtain a general equivalency diploma, and eight times less likely to complete college. And formerly incarcerated people of color are at the greatest educational disadvantage (Couloute, 2018).

Providing educational opportunities in carceral settings has the potential to improve public safety, reduce recidivism, and improve social integration following release (Royer et al., 2021). More than two-thirds of currently incarcerated individuals express a desire to enroll in academic courses or programs while incarcerated (Rampey et al., 2016). One study estimates that recidivism is reduced by 43 percent among those who participate in such educational programs, yet numerous barriers exist to providing them (Davis et al., 2014). For example, some prisons require drug testing for those wishing to participate in higher education programming provided by community-based academic institutions (Royer et al., 2021). Additionally, most incarcerated individuals are eligible for postsecondary education, but access is hampered because incarcerated people are banned from accessing funding for education, such as Pell grants (Oakford et al., 2019).

processing applications due to administrative limitations and wait periods (Wakefield et al., 2023). Not surprisingly, then, data suggest that petition-based record relief has a serious uptake gap. One study evaluating record expungement, not specifically with respect to cannabis, estimated that among people legally eligible for expungement of criminal convictions, only 6.5 percent obtain it within 5 years of eligibility, but those who do obtain it experience higher wages and have a low subsequent crime rate (Prescott and Starr, 2019).

To address the barriers to petition-based record relief, many states and jurisdictions have committed to automatically clearing eligible records for people who have completed their sentences and remained crime free and to expanding the criteria for eligibility for clearance. Since 2018, 12 states (California, Colorado, Connecticut, Delaware, Michigan, Minnesota, New York, New Jersey, Oklahoma, Pennsylvania, Utah, and Virginia) have passed laws that align with the laws and policies⁸ of the Clean Slate Initiative.⁹

Social Equity Business Assistance

A fundamental goal of many state cannabis social equity programs is to help those harmed by cannabis criminalization to benefit financially from the legal market. The criteria for receiving support can include having prior involvement with the criminal justice system; being economically disadvantaged; living in or having resided in an economically disadvantaged area; and other considerations, such as veteran status, race, or ethnicity. The business assistance can include preferential licensing, financial support, and assistance (Hrdinova and Ridgway, 2024). Most cannabis social equity programs include industry support. Alaska, Maine, Montana, and Oregon are the only legal adult-use states without some social equity business assistance.

In 12 states, laws require that a particular portion of cannabis business licenses be allocated to individuals from communities that have been targeted unfairly by past cannabis enforcement. State regulators may also establish additional applicant criteria (Hrdinova and Ridgway, 2024). For example, Connecticut and New York reserve 50 percent of licenses for social equity applicants. New Jersey allocates 25 percent of licenses to applicants from selected impact zones. Other states—including Arizona, Delaware, Nevada, Ohio, Rhode Island, and Washington—specify the

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⁸ https://www.cleanslateinitiative.org/states (accessed March 28, 2024).

⁹ The Clean Slate Initiative is an organization that “passes and implements laws that automatically clear eligible records for people who have completed their sentence and remained crime-free and expands who is eligible for clearance” (para. 1) (https://www.cleanslateinitiative.org [accessed March 28, 2024]).

number of equity licenses awarded, often dividing the numbers into cultivation, manufacturing, retail, and testing licenses. Nevada also has a license for cannabis consumption lounges, half of which are awarded to equity applicants (Hrdinova and Ridgway, 2024).

Twenty states have programs that provide license or business assistance (Hrdinova and Ridgway, 2024). Although each state’s program is different, some examples of license assistance include priority application review, reduced application fees, financial assistance programs to help launch a cannabis business, and education and training programs (Hrdinova and Ridgway, 2024).

Priority application review ensures that specific applications are processed more quickly. For example, the New Jersey Cannabis Regulatory Commission ranks priority groups based on diversity status, owner’s economic and criminal background, and physical location.¹⁰ Applications from higher-ranking groups are reviewed first (Hrdinova and Ridgway, 2024).

Reduced application fees are used in 11 of the 24 adult-use states (Hrdinova and Ridgway, 2024). The programs typically reduce or waive fees related to the initial application. Vermont uses a fee reduction schedule that begins with a full waiver and gradually increases over time, allowing social equity owners to achieve financial sustainability (Vermont CCB, n.d.). Delaware offers special microbusiness licenses with lower fees and less frequent renewals, catering to smaller-scale operations for those without the capital to start a large business (Hrdinova and Ridgway, 2024).

Financial assistance programs that can help launch a cannabis business are part of social equity programs in several states, including California, Colorado, Connecticut, Delaware, Illinois, Massachusetts, and New York. These programs offer funding assistance through grants, microloans, and no- or low-interest loans. How the funds can be used to support the business varies by state, and the loan repayment structures differ based on the loan terms (Hrdinova and Ridgway, 2024).

Technical assistance programs provide support and resources to cannabis business owners. These programs offer training on regulatory compliance, business planning, marketing strategies, and cultivation techniques. Some programs also include access to funding and mentorship opportunities. Colorado’s Accelerator License program helps cannabis business owners from communities impacted by cannabis prohibition by partnering those with social equity licenses with an established cannabis business. The established business can then advise the social equity licensee on how to run a successful business.¹¹

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¹⁰ https://www.nj.gov/cannabis/businesses/priority-applications/ end of page (accessed March 22, 2024).

¹¹ https://sbg.colorado.gov/accelerator-program (accessed March 22, 2024).

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¹² https://business.ca.gov/california-community-reinvestment-grants-program (accessed March 22, 2024).

funding for social programs. There are also social equity considerations regarding cannabis taxation (Yang et al., 2023). Those who have lower incomes and use cannabis may spend a higher proportion of their income on cannabis and thus are more impacted if taxes increase the price of cannabis. So those who are intended to benefit from the program may be paying an increased proportion of the cost (Jernigan et al., 2021).

State Social Equity Programs: Findings

State and local cannabis equity programs are a recent development aimed at addressing the social and economic harms caused by cannabis prohibition, which has disproportionately impacted communities of color. Cannabis legalization has spurred a range of social equity efforts in the United States that encompass criminal justice reform, assistance with industry participation, and community reinvestment programs. While these initiatives hold promise for mitigating the harms of cannabis prohibition, challenges remain in implementation and effectiveness. Addressing these challenges will ensure that social equity is a central feature of the legal cannabis industry. Start-ups may need help staying afloat in competitive markets to contend with predatory rent prices and loan repayments (Gerber, 2022). As these programs continue to develop, monitoring their effectiveness and adjusting as needed will be essential (Title, 2021).

SOCIAL DETERMINANTS OF HEALTH

For decades, research and scholarship have illustrated that social and structural factors—such as race, ethnicity, zip code, education level, employment, and income—impact health outcomes and thereby create significant health inequities (NASEM, 2023a). Systems of power, individual factors, and physiological pathways influence health equity. Systems of power are policies, processes, and practices that determine who gets resources and better opportunities for health. These systems can promote health equity or perpetuate inequities (access to basic needs, humane housing, meaningful work, and reliable transportation). Individual factors concern people’s responses to social, economic, and environmental conditions through their attitudes, skills, and behaviors and their interaction with biological predisposition. Physiological pathways refer to people’s biological, physical, cognitive, and psychological abilities (Peterson et al., 2021).

To understand how cannabis policy contributes to health equity, it is essential to consider the social and structural factors that impact the well-being of individuals and communities. These structural factors affect

local, state, and federal government; industry; and health care systems. The social determinants of health framework acknowledges the social and structural factors that must be addressed to improve health equity. Many different social-ecological models, describe how social and structural factors influence health. Healthy People 2030 and a recent National Academies report categorize the social determinants of health as economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context (HHS, n.d.; NASEM, 2023a). The committee considered how changes in cannabis policy can influence these social and structural determinants of health (Figure 5-2).

safety and security concerns are not paramount (Cohen et al., 2022; Hoffman, 1999; Price, 2014; Treglia et al., 2022). Following the passage of the Drug-Free Workplace Act of 1988 (41 USC 81), which requires federal grant recipients or contractors to establish and maintain a drug-free workplace policy, 40–45 percent of U.S. workers reported the use of drug testing in their workplaces (Carpenter, 2007; Oh et al., 2023). Black workers are tested more frequently than White workers, even controlling for occupation (Becker et al., 2014; Carpenter, 2007). Since employer drug testing can prevent people from acquiring or maintaining a job, these disparities likely impact health equity.

At the committee’s second public meeting, Ryjean Reid described how employer drug testing impacted him personally. He was employed as a first-line manager at an airline and lost his position after testing positive for cannabis last year. Based on his experience with cannabis testing, he said he thinks that “cannabis prohibition creates a second class of citizenship in the United States, and these inequities in enforcement are overall damaging in terms of public health.”

As cannabis policies have shifted, employers have changed drug testing practices. Many cannabis legalization laws have included explicit language protecting employee rights concerning cannabis use outside of regular work hours. According to data from the National Conference of State Legislatures, as of January 22, 2024, 8 of the 24 states with adult-use cannabis legislation (California, Connecticut, Montana, Nevada, New Jersey, New York, Rhode Island, and Washington) had statutes protecting employees’ rights to use cannabis while off duty.¹³ These states have either statutory or constitutional language requiring employers not to discriminate at the time of hiring or against off-duty use of cannabis by employees. However, some of these laws exempt employers in particular occupations (e.g., construction in California). None of these laws prevent employers from testing after an accident or for cause.

The economic impacts of cannabis legalization are complex, with potential benefits and drawbacks for communities. To date, cannabis legalization may not be improving economic inequities. The cannabis industry, while generating tax revenue for a state’s government, may not be benefiting those harmed by cannabis policing, and employer drug testing practices may impact employment status among Black people because the practice is applied inequitably.

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¹³ Data from the National Conference of State Legislatures, last updated January 22, 2024, https://www.ncsl.org/health/cannabis-and-employment-medical-and-recreational-policies-in-the-states (accessed August 14, 2024).

further supported by quasi-experimental evidence comparing academic achievement before and after cannabis prohibition, which supports the connection between cannabis use and poorer school performance (Marie and Zölitz, 2017). Moreover, the 2015–2019 NSDUH revealed that not only youth with cannabis use disorder but also those with subclinical nondisordered cannabis use had more difficulty concentrating and worse academic performance (Sultan et al., 2023). The above research does not conclusively support a causal connection between cannabis use and dropping out of school, as the findings may be subject to potential confounding caused by mental health disorders and other factors (Esch et al., 2014; Lorenzetti et al., 2020). Nonetheless, it supports a plausible connection between cannabis use and dropping out of school, which is why substantial research attention has been paid to the impact of changing cannabis policies on youth substance use.

Enforcement of existing cannabis laws can also impact school attendance and enrollment in at least two ways. First, schools’ zero-tolerance policies mandating suspension or expulsion for simple drug possession directly increase suspensions and expulsions from those schools while also contributing to school alienation, academic deterioration, and delinquency among the affected students (AAP and Committee on School Health, 2003; APA Zero Tolerance Task Force, 2008; Wald and Losen, 2003). A recent survey of 1,080 public schools in 2021 found that 62 percent still retained zero-tolerance policies and that the policies of 85 percent of these schools extended to possession of illegal drugs, which would include cannabis for anyone under age 21 (Perera and Diliberti, 2023).

A second way enforcement might impact school attendance is through additional policing that occurs in low-income and ethnically diverse neighborhoods (Gaston, 2019; Lum, 2010), which can increase the chances that youth in those neighborhoods will be arrested for simple possession or use (Nguyen and Reuter, 2012). These arrests lead to an immediate absence from school due to criminal justice engagements and increase the likelihood of dropping out of school (Kirk, 2009; Kirk and Sampson, 2013), affecting the resources available to the broader school environment (since absenteeism reduces school funding).

Cannabis liberalization policies also have potential effects on school access and quality that warrant further study. To the extent that cannabis legalization policies do not address the criminality of youth possession and use or lead to changes in school zero-tolerance policies, they are likely to have only negative impacts on school access and education quality because they increase the potential for youth cannabis access and use. If, however, legalization policies are coupled with decriminalization statutes, which eliminate the criminal status of simple possession or use of small amounts of cannabis for both adults and people under 21, they may bring some benefit to disadvantaged neighborhoods and schools at risk of differential enforcement of criminalization policies (Tran et al., 2020; Wald and Losen, 2003).

for Black juveniles 2 and 6 years after a policy change in legalizing states compared with control states (Harris and Kulesza, 2023).

The National Institutes of Health previously funded a large-scale, multisite study—the Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS)—which aimed to improve access to services for substance use disorder for justice-involved youth. Although not explicitly focused on cannabis, the JJ-TRIALS framework offers valuable insights for addressing cannabis use among this population (Becan et al., 2020). Previous studies exploring opportunities for engagement with adolescents in the juvenile justice system highlight the potential for diversionary pathways that steer youth away from the criminal justice system and toward treatment and supportive services (Belenko et al., 2017). The Behavioral Health Services Cascade emphasizes the potential transitions youth can navigate across service systems, such as moving from the criminal justice system to the substance use disorder treatment system. It offers a promising framework for addressing cannabis use among justice-involved youth (Belenko et al., 2017).

The impacts of cannabis policy on the quality of health care received, particularly substance use treatment, have received little attention in the literature beyond the issue of how to identify those in need of treatment for cannabis use disorder. The U.S. Preventive Services Task Force (USPSTF et al., 2020) concluded that among adults, screening by asking questions about unhealthy drug use has a moderate net benefit when services for accurate diagnosis of unhealthy drug use or drug use disorders, effective treatment, and appropriate care can be offered or referred; in adolescents, the benefits and harms of screening for unhealthy drug use are uncertain.

The USPSTF has not completed a review specific to interventions for cannabis use disorder. While there is an expansive literature identifying psychotherapeutic treatments for cannabis use disorder, including motivational interviewing, cognitive-behavioral therapy, and contingency management, the literature has consistently found these therapies to be only moderately efficacious in reducing use (frequency and amount) and limited in their ability to achieve abstinence (Babor, 2004; Dutra et al., 2008; Sherman and McRae-Clark, 2016). Furthermore, cannabis use disorder may have inequitable treatment outcomes, as inequities in outcomes related to substance use disorder treatment have persisted for decades for many substances (Dogan et al., 2021). However, only a few randomized controlled trials have specifically examined such outcomes among people of color (Jordan et al., 2022), demonstrating a need to evaluate the treatment this population receives. This issue is particularly concerning given the documented associations between racial discrimination and cannabis use, which may also impact treatment initiation as well as treatment-related outcomes.

use among young adults (aged 18–25) from 2015 to 2019. The study found that, after controlling for individual factors and census tract–level metrics on availability of cannabis in retail outlets, neighborhood disadvantage was statistically significantly associated with increased weekly and near-daily use of cannabis (Rhew et al., 2022). Another study, in California, examined trends in rates of hospital emergency department visits and discharges involving cannabis use disorder at the community level from 2010 to 2019 and found greater increases in both outcomes in communities of color (Cao et al., 2022).

Evidence on cannabis policies contributing to neighborhood crime is mixed, which may be due to differences in the measurement of neighborhoods and in the types of crimes examined. A study in Denver, Colorado, found that the opening of a cannabis retail outlet was associated with higher rates of all types of crime, except for murder and car theft, in surrounding neighborhoods (Hughes et al., 2020). Another study, in Seattle, Bellevue, and Tacoma (all in Washington state), found modest but statistically significant increases in property crime in census block groups containing new cannabis retail outlets (Thacker et al., 2021). However, other studies have found a decrease in violent crime, including rapes and property crime, in Washington and Oregon with the opening of retail outlets (Dragone et al., 2019). Even when cannabis retail outlets are associated with crime (whether positively or negatively), it is unclear to what extent these associations are due to the current rules placed on cannabis outlets because of federal prohibition. Specifically, cannabis retail stores are mainly cash businesses, which are often the target of crime. This is why retail stores often have tight security systems with cameras, which may lead to lower crime in their vicinity (Chang and Jacobson, 2017).

Because of zoning laws or by choice, cannabis retailers may be concentrated in neighborhoods with historical disadvantages, which raises questions about whether the presence of an outlet creates a disadvantage, or these outlets are more likely to exist in disadvantaged neighborhoods. For example, one study examining neighborhood characteristics associated with density of cannabis retailers in Oklahoma documented a disproportionate concentration of retailers in census tracts with a larger proportion of individuals lacking health insurance and living below the federal poverty level (Cohn et al., 2023). Importantly, this same study found that a large proportion of census tracts classified as rural had at least one retailer, which may have implications for geographic differences in access to cannabis. A similar study in Washington state indicated that cannabis retailers are disproportionately located in communities with more significant disadvantages, as defined by American Community Survey composite scores (Williams et al., 2023). A study of both licensed and unlicensed cannabis retailers in California in 2018 found that not only were legally licensed retailers more likely to be found in neighborhoods

with higher poverty and in communities of color, but so, too, were unlicensed stores (Unger et al., 2020).

Retail availability of cannabis has been associated with greater cannabis use and cannabis-related health outcomes, although more research in this area is needed. Greater retail availability of cannabis has been associated with lower odds of perceiving cannabis smoking as harmful. A study in California found that having an adult-use cannabis retailer within 2 miles of a person’s home and signs promoting the health benefits of cannabis were associated with both increased use and lower perceived risk among adults (Han and Shi, 2023). Another study, in rural Oklahoma, found that the presence of cannabis retailers increased exposure to cannabis-related advertising among adolescents (Livingston et al., 2023). Retail availability of cannabis has also been associated with greater odds of prenatal cannabis use among pregnant individuals in California (Young-Wolff et al., 2021).

A recent systematic review of the density of cannabis retailers (Cantor et al., 2024) found consistent positive associations between greater access to cannabis retailers across several outcomes. Greater use of health care services and increased poison control calls directly due to cannabis were observed in 10 of 12 included studies (83 percent). Increased cannabis use and cannabis-related hospitalizations during pregnancy were observed in 4 of 4 included studies (100 percent). Frequent cannabis use in adults and young adults was observed in 7 of 11 included studies (64 percent). There are no consistent associations between greater cannabis retail density and increased frequent cannabis use in adolescents (25 percent of included studies), use of health care services potentially related to cannabis (33 percent of included studies), or increased adverse neonatal birth outcomes (26.8 percent of included studies) (Cantor et al., 2024).

Social and Community Context

Cannabis policy may play a role in weaving the fabric of a community. This social fabric is built on strong social networks, a sense of collective efficacy (the ability to work together), and a focus on neighborhood safety (Barnett and Casper, 2001; Halliday et al., 2020). However, unequal enforcement of cannabis prohibition may have eroded trust, particularly within minoritized communities. Cannabis legalization may change that, but the committee’s analysis of arrest data shows that disparities in arrest rates persist.

Beyond policy changes, social factors within communities also significantly influence substance use patterns. Concepts such as collective efficacy and social cohesion, which measure the strength of relationships and community bonds, are crucial for understanding this dynamic. Communities with low collective efficacy, often facing economic hardship, may struggle to enforce social norms (Kawachi and Berkman, 2000; Sampson, 2017).

Low collective efficacy could lead to less intervention in risky adolescent behavior, potentially increasing youth substance use. Studies support this link, showing a correlation between lower parental oversight and higher youth cannabis use (Handley et al., 2015). However, the relationship between social factors and substance use is complex. Strong communities with high adult involvement can also lead to lower youth substance use (Kawachi and Berkman, 2000). There is, however, a potential downside: strong social ties may normalize substance use if adults themselves partake (Fagan et al., 2015; Mayberry et al., 2009). Additionally, parents in neighborhoods with high collective efficacy may feel less pressure to supervise their children directly, assuming that the community shares that responsibility. This assumption can have unintended consequences.

The impact of changes in cannabis policy on these social processes remains unclear. While research on other substances, such as alcohol, offers some insights, the specific effects of cannabis policy within the context of a community’s social fabric require further exploration.

CONCLUSIONS AND RECOMMENDATIONS

Cannabis policy has considerable impacts on health equity. Cannabis arrests and incarceration have contributed to substantial social and economic inequities due to the arrest, fines, loss of income, and collateral consequences. Those arrested face restrictions in voting, employment, housing, public assistance, immigration, family integration, and education.

Conclusion 5-1: Cannabis prohibition and traditional law enforcement tools (arrest and prosecution) have disproportionately impacted communities of color, leading to adverse collateral consequences that negatively affect people’s lives in such areas as education, employment, and health care access. While policy reforms have decreased arrest rates, evidence suggests that racial inequities may persist, highlighting the need for further action to address these inequities.

The data needed to evaluate whether changes in cannabis policy have reduced inequities associated with criminal justice entanglement are lacking. To evaluate the impact of cannabis policy changes on social and health equity, it is crucial to understand who is being arrested, for what, and with what consequences. National crime data do not adequately capture demographic characteristics (e.g., race, ethnicity, income). Prior reports of the National Academies have documented problems with crime statistics and the data infrastructure supporting those systems (Box 5-1). The recommendations from those reports highlight the need for better and more accurate data, which would allow for improved monitoring of how changes in cannabis policies are affecting inequities in criminal justice.

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